Employment Application
Quilceda Community Services
9610 48th DR NE, Marysville, WA 98270
(360) 653-2324
APPLICANT INFORMATION
FULL NAME:
First Name
Middle Initial
Last Name
DATE:
-
Month
-
Day
Year
Date
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMAIL:
example@example.com
PHONE:
Format: (000) 000-0000.
DATE AVAILABLE:
-
Month
-
Day
Year
Date
DESIRED SALARY:
POSITION APPLYING FOR:
Are you legally eligible to work in the U.S.?
YES
NO
Have you ever worked for this company?
YES
NO
Do you have a social security #?
YES
NO
EDUCATION
HIGH SCHOOL:
Address:
From:
To:
Did you graduate?
YES
NO
Diploma:
COLLEGE:
Address:
From:
To:
Did you graduate?
YES
NO
Degree:
OTHER:
Address:
From:
To:
Did you graduate?
YES
NO
Degree:
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EMPLOYMENT HISTORY
Company:
Phone:
Format: (000) 000-0000.
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Job Duties:
Start date:
-
Month
-
Day
Year
Date
End:
-
Month
-
Day
Year
Date
Reason for Leaving:
Company:
Phone:
Format: (000) 000-0000.
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Job Duties:
Start date:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Reason for Leaving:
Company:
Phone:
Format: (000) 000-0000.
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Job Duties:
Start date:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Reason for Leaving:
Company:
Phone:
Format: (000) 000-0000.
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Job Duties:
Start date:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Reason for Leaving:
2
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TRAINING
Do you possess a current: HCA
YES
NO
NAC
YES
NO
First Aid
YES
NO
CPR
YES
NO
Blood Borne Pathogens
YES
NO
Food Handler's Permit
YES
NO
PERSONAL INFORMATION
Within the last seven years, have you pleaded guilty, been convicted, fined, imprisoned or placed on probation for violation of any law, police regulation or ordinance(s), excluding minor traffic violations?
YES
NO
If yes, please explain:
Within the past 10 years, have you been discharged or forced to resign from misconduct or unsatisfactory service from any position?
YES
NO
If yes, please explain:
TRANSPORTATION
Do you have a current Driver's License?
YES
NO
If Yes, long?
Do you have motor vehicle insurance?
YES
NO
Have you had any accidents during the past three years?
YES
NO
If Yes, How many?
If employed by Quilceda Residential Services, will you have transportation to and from your work site?
YES
NO
REFERENCES
Full Name:
Relationship:
Company:
Phone:
3
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Full Name:
Relationship:
Company:
Phone:
Format: (000) 000-0000.
Full Name:
Relationship:
Company:
Phone:
Format: (000) 000-0000.
DISCLAIMER AND SIGNATURE
I authorize Quilceda Community Services to verify my personal, educational, vocational, and employment history. I also authorize any former employer, individual, business, educational or vocational institution, or government agency to provide QCS with any information they have about me. I release and hold harmless QCS and all information providers from any liability arising from the sharing or receipt of this information. I further agree that if I am employed, I will provide verification of my education, experience and certification. I also agree that falsification of any part of this application shall be sufficient cause for dismissal. References and personal information will be regarded as confidential and shall not be revealed to me. Quilceda Community Services is authorized to request the Washington State Patrol and the FBI to make available a prospective employees or volunteers record for conviction of offenses against children or other persons, adjudication of child or adult abuses in a civil action, disciplinary board final decisions and any subsequent criminal charges associated with the conduct that is subject of the disciplinary boards final decision. Misrepresentation or willful omission of facts shall be sufficient cause for disqualification of this application or termination of employment. I hereby certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
Signature of Applicant
Date
-
Month
-
Day
Year
Date
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